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Rule 1959. Forms for Use in Protection of Victims of Sexual Violence or 

Intimidation Actions. Notice and Hearing. Petition. Temporary Protection Order. 

Final Protection Order.

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(b) The petition in an action filed pursuant to the Act shall be identical in 

content to the following form: 

(Caption)

PETITION FOR PROTECTION OF VICTIMS OF 

SEXUAL VIOLENCE

SEXUAL VIOLENCE AGAINST A MINOR CHILD

INTIMIDATION

1. Plaintiff:

_____________________________________________________________________

First Middle Last Name

Plaintiff’s Address: ______________________________________________________

 Plaintiff’s address is confidential pursuant to 42 Pa.C.S. § 62A11.

Plaintiff’s Date of Birth: _______________________________________________

I am filing this petition on behalf of myself or another person.

If you checked “myself,” please answer all questions referring to yourself as “Plaintiff.” If 

you checked “another person,” please answer all questions referring to that person as 

“Plaintiff,” and provide your name and address below.

Name: __________________________________________________________

Address: _________________________________________________________

If you checked “another person,” indicate your relationship to the plaintiff:

_____________________________________________________________________
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2. Defendant:

________________________________

First Middle Last Name

Defendant’s Address: 

________________________________

________________________________

DEFENDANT IDENTIFIERS

DOB HEIGHT

SEX WEIGHT

RACE EYES

HAIR

SSN

DRIVERS

LICENSE #

EXP DATE STATE

3. Name(s) of other designated person(s) under 42 Pa.C.S. § 62A07(b)(1):

____________________________________________________________________

4. Is there a relationship between Plaintiff and Defendant? ________. If yes, what 

is the relationship?

_____________________________________________________________________

5. Have Plaintiff and Defendant been involved in any other legal proceedings? If 

so, state when and where the case was filed and the court docket number, if known: 

_____________________________________________________________________

_____________________________________________________________________

6. Has Defendant been involved in any criminal proceedings? 

______________________________________________________________________

If you answered Yes, is Defendant currently on probation or parole? 

_____________________________________________________________________

7. (a) The facts of the most recent incident of sexual violence are as follows: 

Approximate Date: ____________________________________________________

Approximate Time: ____________________________________________________

Place: ________________________________________________________________

Describe in detail what happened, including any physical or sexual abuse, threats, 

injury, incidents of stalking, medical treatment sought, and/or calls to law enforcement 

(attach additional sheets of paper if necessary): 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
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(b) The facts of the most recent incident of intimidation are as follows:

Approximate Date: ______________________________________________________

Approximate Time: ______________________________________________________

Place: ________________________________________________________________

Describe in detail what happened, including medical treatment sought, and/or calls to

law enforcement (attach additional sheets of paper if necessary): 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

8. If Defendant has committed prior acts of sexual violence or intimidation against 

Plaintiff, describe these prior incidents, and indicate approximately when such acts 

occurred (attach additional sheets of paper if necessary): 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

9. Identify the sheriff, police department, or other law enforcement agency in the 

area in which Plaintiff lives that should be provided with a copy of the protection order: 

______________________________________________________________________

10. Is [there an]Plaintiff in immediate and present danger [for further acts of 

sexual violence or intimidation] from Defendant[ against Plaintiff]? If so, please 

describe: ______________________________________________________________

FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A 

TEMPORARY ORDER AND, AFTER A HEARING, A FINAL ORDER THAT WOULD 

INCLUDE ALL OF THE FOLLOWING RELIEF (CHECK ALL FORMS OF RELIEF 

REQUESTED): 

A. Restrain Defendant from having any contact with the victim, including, but not 

limited to, entering the victim’s residence, place of employment, business, or school. 

B. Prohibit indirect contact through third parties.

C. Prohibit direct or indirect contact with other designated persons.
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D. Order Defendant to pay the fees of this action. 

E. Order the following additional relief, not listed above: 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

F. Grant such other relief as the court deems appropriate, including, but not limited 

to, issuing an order under 42 Pa.C.S. § 62A11(b) related to the non-disclosure of the 

victim's address, telephone number, whereabouts or other demographic information.

G. Order the police, sheriff or other law enforcement agency to serve the Defendant 

with a copy of this petition, any order issued, and the order for the hearing. Plaintiff will 

inform the designated authority of any addresses, other than Defendant’s residence, 

where Defendant can be served. 

VERIFICATION

I verify that the statements made in this petition are true and correct to the best of 

my knowledge. I understand that false statements herein are made subject to the 

penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

_____________________________________________________________________

Signature 

_____________________________________________________________________

Date 

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